Participant ID Initials

Section 1: Demographics

1.1 Interviewer name & code no.…………………………………

1.2 Date of interview: / /

dd mm yyyy
1.3 Residence codes:

1.4 Was written Informed Consent obtained?  No  Yes

If no, please do not proceed.

1.6 Gender:  Male  Female

1.7 Date of birth: / /

dd mm yyyy
If year of birth not known ask or estimate age (years) |__|__| AGE

1.8 Marital status:  Married

 Single- never married
 Divorced
 Separated
 Widowed

1.9 Religion:  Catholic

 Protestant
 Muslim
 Pentecostal
 Traditional
 Other………..

1.10 Highest level of education attained:  None

 Primary (P1-7)
 Secondary (S1-6)
 Tertiary (University)

Section 2: Knowledge about stroke

2.1 What organ of the body is affected by stroke:  Brain  Heart
 Kidney  Liver
 Lungs  Don’t know  Other…………………
2.2 Is stroke preventable? : Yes  No

2.3 Can a person have stroke more than once? : Yes  No

2.4 Does stroke have an effect on daily activities like driving a car, dressing, use of the toilet
and having a job? :  Yes  No

What do you believe causes a stroke? -

 Demons  hypertension  don’t know

 Witch craft  cigarette smoking  Bad diet
 God’s will  Fatty foods  alcohol
 Atherosclerosis  high cholesterol  Stress
 Angry ancestral spirits  Obesity
 Oral contraceptives  lack of exercise
 Inheritance
 Others (please specify)…………………………………………………………

What do you believe are risk factors for stroke?

3.1 Do you know any risk factors for stroke?  Yes  No

If Yes, what are the risk factors for stroke that you know of? Please tick all that applies

 Old age  hypertension

 Diabetes  cigarette smoking
 Heart disease  alcohol
 Atherosclerosis  high cholesterol
 Obesity  genetics (hereditary)
 Stress  lack of exercise
 Poor hygiene  headache or migraine
 Cancer  oral contraceptives
 Bad diet  tremors
 Others

Knowledge of stroke warning signs

3.2 Do you know any warning signs of stroke?  Yes  No

3.3 If Yes, what are the warning signs of stroke that you know of? Please tick all that applies

 Dizziness  blurred or double vision or loss of vision

 Headache  sudden difficulty in speaking or understanding or reading
 Tiredness  fever/sweating
 Shortness of breath  Chest pain or chest tightness
 Nausea/vomiting  weakness of any part of the body
 Weakness of one side of the body  paralysis of any part of the body
 Paralysis of one side of the body fainting black out collapse
 Numbness tingling sensation or dead sensation of any body part
 Numbness tingling sensation or dead sensation of one side of the body
Others (please specify…………...

What would be your planned response to an event of stroke?

 Call general practitioner or family doctor

 Ask family members or relatives to help
 Go to chemist for advice or medication
 Self medication
 Ask friend or neighbours for help
 Go to hospital
 Visit community health centre
 Visit alternative health care providers (herbal med, traditional healers),
 Seek spiritual healing (prayer)
 Combination of hospital and tradition
 Combination of hospital and faith
 Invite a Physiotherapist
 Others (please specify)

Sources of information about stroke

What are your sources of information about stroke? Please tick all that applies
 Health care providers  Friends and relatives
 Radio  TV  News papers
 Electronic media  Others (please specify)…………